Insights & Analysis
There’s one constant in healthcare: change. Count on us to break down the trends so you can stay up to date. Follow our take on each piece of this deep, intertwined, and often perplexing industry to find opportunities and practical approaches to move healthcare forward.
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Medicare Waste Refunds Could Cost Manufacturers Over $210M Annually
Forty-four Part B drugs could be subject to new CMS wastage refund requirements according to an Avalere analysis of Medicare claims.
CMS Requests Input on Payment Policy for New ESRD Therapies
Recent Medicare rulemaking requested stakeholder feedback on potential payment system changes to support access to therapies for patients on dialysis.
Inflation Reduction Act Renews Focus on Value Assessment in the US
Government price-setting provisions in the IRA have highlighted the diverse nature and interpretation of value across the US healthcare system.
Navigating the Road to RSV Prevention
Numerous novel respiratory syncytial virus (RSV) preventive products, including vaccines and monoclonal antibodies (mAbs), are in late-stage clinical development. Consequently, the RSV prevention landscape is expected to transform in the coming years. Adequate preparation to incorporate the use of these new tools should consider the regulatory and recommendation pathways and their implications for coverage and reimbursement.
What Braidwood Management v. Becerra Means for Preventive Services
The court’s ruling could impact $0 cost-sharing coverage of PrEP and other USPSTF-recommended services.
Opportunities for Savings Within Orthopedic Value-Based Bundles
It is critical for orthopedic providers to understand key cost drivers to identify opportunities for savings in bundled payment arrangements with private payers.
EOM Participation Likely Influenced by Prior OCM Experience
With EOM’s immediate downside risk, the model may appeal more to practices ready to implement care transformation activities and value-driven decision making.
New Analysis of Trends in Part D Generic Tiering, Pricing, and Patient Spending
New Avalere analysis examines longitudinal trends across a cohort of generic drugs, finding increases in aggregate patient spending over time and in placement on higher tiers in Medicare Part D.
Reducing Disparities in Medicine: Advancing Equity in Clinical Trials
Clinical trial participation has not appropriately represented all patient populations, which risks overlooking all patients’ perspectives and potential health outcomes. Numerous federal efforts have taken place this year to enhance equity in clinical trials, however, a lack of legislative progress leaves an opportunity for life science companies to get involved.
340B Reimbursement Proposal Could Reduce Payments for 80% of Hospitals
To assess how changes in OPPS payment for reimbursement of drugs under the 340B program would affect hospital reimbursement and Medicare Part B beneficiary cost sharing, Avalere estimated the impact of increasing reimbursement for 340B drugs in Medicare Part B to ASP + 6%. The analysis finds that most hospitals would see overall payment decreases, while payments would be subject to higher cost sharing.
Patient–Provider Collaboration: Shared Decision Making in Cancer Care
In the latest installment of Avalere’s ongoing insight series about shared decision making, Michelle Bruno, Associate Principal in Avalere’s Center for Healthcare Transformation, describes the role it can play in cancer care.
10 Questions on Dobbs v. Jackson’s Reproductive Health Impact and More
Uncertainty related to the Dobbs ruling could have downstream effects on reproductive healthcare that go beyond abortion.
Analysis of CMMI Models Projects Costs Rather than Savings
Avalere estimates that the CMMI will produce net costs of approximately $9.4 billion through 2026, in contrast to the CBO’s projected net savings of $34 billion.
Overview and Implications of CMS’s Proposed Changes to MA RADV
If finalized as proposed, the changes to the Risk Adjustment Data Validation process could have a substantial impact on Medicare Advantage plans and enrollees.
Several Changes to Adult Vaccine Access Enacted Through IRA
The IRA will expand adult vaccine access by mandating coverage without cost sharing for all adult vaccines in Medicare Part D and Medicaid.
Drug Pricing Policies Under Inflation Reduction Act Raise Operational Questions
Understanding where federal agencies will make key determinations on details of the IRA’s policies will be crucial for stakeholders seeking to shape implementation and prepare for their impact.
Shared Decision Making: An Insight Series on Clinician-Patient Collaboration Improving Engagement & Outcomes
A new series explores how shared decision-making can be applied in multiple therapeutic areas to reach patient, clinician, and other stakeholders’ goals.
FDA-CMS Collaboration: History and Future Outlook
FDA and CMS have historically had complementary roles, yet prior collaboration between the agencies generally has been limited.
Vaccine Incentives for Providers Would Change Due to 2 MPFS Proposals
CMS is proposing to update vaccine administration reimbursement rates annually and make changes to adult vaccination quality metrics, beginning in 2023.
Comparing Medicare FFS Pneumococcal Vaccination Rates in 2019 and 2020
A new study from Avalere analyzes age, race and ethnicity, and Medicare-Medicaid dual-eligibility status of Medicare Fee-For-Service (FFS) beneficiaries with pneumococcal vaccine claims in 2019 and 2020.